Glycemic control and maternal and fetal outcomes in pregnant women with type 1 diabetes according to the type of basal insulin.

OBJECTIVE: To examine the potential role of the type of basal insulin on glycemic control and maternal and foetal outcomes in pregnant women with type 1 diabetes (T1DM). STUDY DESIGN: Retrospective cohort study of pregnancies attended at 18 Spanish tertiary hospitals. INCLUSION CRITERIA: T1DM, singleton pregnancies, delivery between 2002-2010, and use of the same basal and prandial insulin from before pregnancy until delivery. RESULTS: A total of 1534 pregnancies were included. The basal insulin most commonly used was Neutral Protamine Hagedorn (NPH) (51.7%), followed by glargine (23.2%) and continuous subcutaneous insulin infusion (CSII) (21.1%). CSII users had longer diabetes duration. Multiple logistic regression analysis showed that CSII was independently associated with lower doses of insulin, higher glycated haemoglobin (HbA1c) in all trimesters, and higher rates of miscarriage, preterm birth and neonatal hypoglycemia. Glargine was related to a higher risk of preterm birth and a small-for-gestational age infant (SGA). The odds ratios (OR) of the associations between insulin type and clinical outcomes (from 0.642 to 4.894) have a relevant magnitude. CONCLUSIONS: In this observational study of pregnant women with T1DM, the type of basal insulin was independently associated with metabolic variables and foetal outcomes.

[Thyroid dysfunction in pregnancy. Consensus document. Andalusian Society of Endocrinology and Nutrition (SAEN)]. / Abordaje del manejo de la disfunción tiroidea en la gestación. Documento de consenso de la Sociedad Andaluza de Endocrinología y Nutrición (SAEN).

A position statement on the diagnosis and treatment of thyroid dysfunction in pregnancy has been agreed on behalf of The Sociedad Andaluza de Endocrinología y Nutrición (SAEN), based on a review of the literature to date and all good clinical practice guidelines. The document is set out in different sections as regards the diagnosis and treatment of, overt and subclinical hypo- and hyperthyroidism, isolated hypothyroxinaemia and postpartum thyroiditis. It also justifies the implementation of universal screening for thyroid dysfunction in pregnancy, and provides practitioners who care for these patients with tool for rational decision making.

Oleic acid from cooking oils is associated with lower insulin resistance in the general population (Pizarra study).

AIM: To evaluate the relation between type of dietary fatty acid and degree of insulin resistance. DESIGN: A cross-sectional study. METHODS: Anthropometrical data were measured in 538 subjects, aged 18-65 Years, selected randomly from the municipal census of Pizarra (Spain). An oral glucose tolerance test (OGTT) was given to all subjects and measurements were made of glycemia, insulinemia and the proportion of fatty acids in plasma phospholipids. Insulin resistance (IR) was estimated by homeostasis model assessment. Samples of cooking oil being used were obtained from the kitchens. The strength of association between variables was measured by calculating the odds ratio (OR) from logistic models, and the relationships were measured by linear correlation coefficients. RESULTS: Insulin resistance was significantly less in people who used olive oil compared with those who used sunflower oil or a mixture. Statistical significance remained in the group of people with normal OGTT after adjusting for obesity. In the whole sample, IR correlated negatively with the concentration of oleic acid (r=-0.11; P=0.02) and positively with that of linoleic acid (r=0.10; P=0.02) from the cooking oil. In subjects with normal OGTT, IR correlated negatively with oleic acid from cooking oil (r=-0.17; P=0.004) and from plasma phospholipids (r=-0.11; P=0.01) and positively with the concentration of linoleic acid in cooking oil (r=0.18; P=0.004) and plasma phospholipids (r=0.12; P=0.005). The risk (OR) of having raised IR was significantly lower in people who consumed olive oil, either alone (OR=0.50) or mixed (OR=0.52) compared with those who consumed only sunflower oil. CONCLUSION: There is an association between the intake of oleic acid, the composition of oleic acid in plasma phospholipids and peripheral insulin action.

Serum leptin and habitual fatty acid dietary intake in patients with type 1 diabetes mellitus.

OBJECTIVE: To study the contribution of a normal intake of nutrients to the variability of serum leptin concentrations in persons with type 1 diabetes mellitus. DESIGN: We studied the relation between serum leptin and nutrient intake in a cross-sectional study. METHODS: Serum leptin measured by radioimmunoassay, nutritional data determined by a self-administered 7-day nutritional questionnaire, and the fatty acid composition of the serum phospholipids (measured by thin layer chromatography and gas chromatography) were determined in 60 patients with type 1 diabetes mellitus. Correlation and regression analyses were performed between serum leptin and dietary fatty acids and serum phospholipid fatty acids. RESULTS: In the prediction models for the concentrations of serum leptin in men with type 1 diabetes mellitus, the dietary fatty acids displaced the anthropometric variables, and were independent of the serum testosterone concentrations. This fact remained when the prediction was made on the basis of indirect markers of the intake, such as the serum phospholipid fatty acids. In the women, the fatty acids from the diet or from the serum phospholipids also partly explained the variation in serum leptin, although not displacing the anthropometric variables. CONCLUSIONS: Our data suggest that, in non-experimental conditions, the concentrations of serum leptin in men with type 1 diabetes mellitus and, to a lesser extent, those in women with diabetes, may be influenced by the composition of the habitual diet, especially the type of dietary fat.

[The quality of the care in parenteral nutrition: the benefits after the incorporation of a nutritional support team]. / Calidad asistencial en nutrición parenteral: beneficios tras la incorporación de un equipo de soporte nutricional.

GOALS: The purpose of the study was to analyze the quality of the prescription and follow-up of the total parenteral nutrition (PNT) before and after the incorporation of a nutritional support team (NST). MATERIAL AND METHODS: A random sample of 96 patients was selected retrospectively, with 48 prior to the incorporation of the NST (the Non-NST group) and 48 after its incorporation (the NST group), to whom TPN was prescribed. The following points were assessed: 1. The existence of a minimum analytical and nutritional assessment, prior to the incorporation of TPN; 2. The follow-up of the same. RESULTS: The average duration of TPN per patient was 13.8 days without differences between the two groups. There is a written record of the weight and height in 15% and 10% of cases, respectively, in the Non-NST group as opposed to 100% and 99% in the NST group (p < 0.0001). Prior to the incorporation of the NST, the nutritional requirement was not verified in any patients (0%) as opposed to 97% afterwards. Statistically significant differences were detected in the measurement of albumin prior to the start of TPN (p < 0.01). During the analytical follow-up, statistically significant differences were detected in the measurement of: blood tests (p < 0.05); basic biochemistry (p < 0.01); general biochemistry, magnesium, zinc, pre-albumin, transferrin and nitrogen balance (p < 0.0001). In the TPN follow-up, the Non-NST group did not change any of the components contained in it (in terms of volume, macro or micronutrients) in 81% of patients, while 17% had one change and 2% had 2 or more changes, as opposed to 27%, 42% and 31%, respectively in the NST group (p < 0.0001). There were no significant differences in metabolic complications between the two groups. CONCLUSIONS: The implementation of a nutritional support team in charge of the prescription and follow-up of TPN has notably improved the quality of these follow-up studies.

[Ebstein's anomaly related with significant pericardial effusion. Report and analysis of a case]. / Anomalía de Ebstein relacionada con derrame pericárdico importante. Informe y análisis de un caso.

Ebstein's anomaly is a malformation of the tricuspid valve characterized from the clinical view point by dysnea, evolutive cyanosis and fatigue. Is it characterized anatomically by a downward displacement of the tricuspid valve into the right ventricle due to anomalous attachment of the tricuspid leaflets. Because of the abnormally situated tricuspid orifice, a portion of the right ventricle lies between the atrioventricular ring and the origin of the valve, that is, an "atrialized" segment of the ventricle, and they have a functionally small ventricular chamber. Roentgenographic studies, usually demonstrate a characteristic enlarged heart. The globular-shaped heart on a chest X-ray may closely resemble the picture usually associated with a large pericardial effusion. The ecocardiographic study is more specific for the differential diagnosis, and usually eliminates one pathology but confirms the other. The patient that we are presenting is unusual, and, as far as we know, it is the only in the literature case in which there is a coexistence of the important pericardial effusion and the Ebstein's anomaly. We review the functional abnormalities of the right ventricle with Doppler and two-dimensional echocardiography in this patient.

Abordaje del manejo de la disfunción tiroidea en la gestación. Documento de consenso de la Sociedad Andaluza de Endocrinología y Nutrición (SAEN) / Thyroid dysfunction in pregnancy. Consensus document. Andalusian Society of Endocrinology and Nutrition (SAEN)

En nombre de la Sociedad Andaluza de Endocrinología y Nutrición (SAEN) se ha elaborado un consenso sobre la atención a la mujer gestante que presenta algún tipo de disfunción tiroidea, basándose en la revisión de la bibliografía actualizada y sobre todo de las guías de buena práctica clínica. Se desarrolla bajo distintos epígrafes o apartados en los que se contempla tanto el diagnóstico como el tratamiento del hipotiroidismo clínico y subclínico, el hipertiroidismo franco y subclínico, la hipotiroxinemia y la tiroiditis posparto, así como la justificación de la realización de cribado universal de la disfunción tiroidea durante la gestación, proporcionando a los profesionales que asisten a estas pacientes un arma de toma de decisiones razonada (AU)

A position statement on the diagnosis and treatment of thyroid dysfunction in pregnancy has been agreed on behalf of The Sociedad Andaluza de Endocrinología y Nutrición (SAEN), based on a review of the literature to date and all good clinical practice guidelines. The document is set out in different sections as regards the diagnosis and treatment of, overt and subclinical hypo- and hyperthyroidism, isolated hypothyroxinaemia and postpartum thyroiditis. It also justifies the implementation of universal screening for thyroid dysfunction in pregnancy, and provides practitioners who care for these patients with tool for rational decision making (AU)

[A study of left ventricle filling using pulsed Doppler in patients with a high prevalence of atherosclerosis]. / Estudio del llenado ventricular izquierdo con Doppler pulsado en pacientes con prevalencia alta para aterosclerosis.

We studied the left ventricular diastolic function with Doppler Echocardiography in 61 patients: the first group (A) was conformed by 20 patients with cerebral stroke in evolution (24 to 48 hours) with age between (45 to 63 year old) every one had carotid obstructive lesion shown by angiography. The (B) group had 21 patients with ischemic heart disease and all of them had selective coronary arteriography with atheromatous obstructive lesions (45 to 63 years old); 17 of this patients had previous myocardial infarction. The third group (C) was formed by 20 healthy people between 40 and 62 years of age. We found an increase in the late diastolic peak velocity, in the (A/E) ratio in the early diastolic time; in the early diastolic acceleration and in early diastolic desceleration. The difference between groups (A) and (B) with the (C) was evident (P less than 0.001). We conclude that patients of (A) and (B) groups had reduced left ventricular compliance and the (B) group with evidence of ischemic heart disease show more prominent abnormality.

[The antihypertensive effect of lisinopril in a single daily dosage. A study of arterial pressure with ambulatory monitoring]. / Efecto antihipertensivo del lisinopril en dosis única diaria. Estudio de presión arterial con monitoreo ambulatorio.

We studied 25 patients with hypertension documented through ambulatory blood pressure monitoring (ABPM) to know the antihypertensive effect of Lisinopril and its action throughout the day. ABPM was done in all patients after two weeks of washout (phase 1). Then patients took 20 mg daily of Lisinopril during four weeks and after that ABPM was repeated (phase 2). Finally, those patients who persisted with high blood pressure received 40 mg daily of Lisinopril during four more weeks and again ABPM was repeated (phase 3). We found statistic difference in the systolic and diastolic blood pressure among the three phases. During the first phase there were 17 patients (68%) with high blood pressure and this number decreased to 8 (32%) in the second one and to 7 (28%) in the third phase. The results show that Lisinopril has satisfactory antihypertensive effect in about 40% of patients. Nevertheless 20% of the case remained with high blood pressure despite treatment with 40 mg of Lisinopril. On the other hand, both, systolic and diastolic blood pressure decreased satisfactory during the night with the dosage received in the morning. We concluded that Lisinopril has moderate effect when it is given as monotherapy and, it has satisfactory effect all over the day.

[The electrocardiographic changes in patients stung by scorpions]. / Alteraciones electrocardiográficas en sujetos picados por alacrán.

Scorpion sting is a hazardous and potentially lethal condition. Venom of some variety of scorpion can cause dramatic cardiovascular and electrocardiographic changes, that have been related to heart stimulation by autonomous nervous system. We prospectively studied 722 patients following scorpion sting. Mean age for the group was 25.5 +/- 18.3 years. 67% were less than 30 years of age. In 294 patients (40.7%) we found electrocardiographic changes. These cases were followed until those changes disappeared. First degree atrioventricular block was found in 10.2%. Intraventricular conduction disturbances in 12.8% with predominance of right bundle branch block. In 11% we found arrhythmias. In 15% reversible ventricular repolarization changes. Of this no one died. This lack of mortality could be attributed to a prompt therapeutic intervention.

[Trends of antidiabetic drug prescriptions in Andalucia (1986-1994)]. / Tendencias de prescripción de medicamentos antidiabéticos en Andalucía (1986-1994).

OBJECTIVE: Tendencies in the consumption of antidiabetic agents in Andalusia between 1986-1994 were analysed, with special emphasis on the impact of the introduction of acarbose and mechanized systems for the injection of insulin. METHODS: The information concerning consumption was obtained from the data bases of the Andalusian Health Service and the Ministry of Health which contain details of the items sold in community chemists and charged to the National Health System. Data are expressed as defined daily doses per 1000 inhabitants per day (DID). RESULTS: Insulin consumption rose from 4.67 DID in 1986 to 9.33 DID en 1994, an increase (delta) of 99.8%. All types of insulins contributed to the increase, with the mixtures rising most (delta 275%). Intermediate insulins were the most used. Prefilled syringes accounted for 25% of all insulin dispensed in 1994. Consumption of oral antidiabetic agents (OAA) rose from 12.75 DID in 1986 to 20.92 DID in 1994 (delta 64%). The most prescribed OAAs during these years were second generation sulphonylureas, representing 83% of those dispensed in 1994, followed by acarbose (11%), biguanides (3.8%), and first generation sulphonylureas (2.1%). CONCLUSIONS: There was a notable increase in the consumption of insulins and OAAs. Although the tendency in the consumption differs from that expected according to consensus agreements, qualitative changes were seen, suggesting an improvement in prescription habits. The appearance of mechanized injection systems for insulin and of acarbose have clearly modified prescription habits.

Does the intake of nuts and seeds alter the appearance of menarche?

BACKGROUND: The nutritional state reportedly influences the age of menarche. In this work we investigated the potential relationship between the intake of various types of foods and the age of menarche, irrespective of body weight. METHODS: An overall 777 schoolgirls of ages between 8 and 16 years from Benalmádena (Málaga, Spain) were subjected to a cross-sectional study involving: the age of menarche as the dependent variable; and the weight, body mass index, skinfold thickness, food intake (estimated from weekly food frequency questionnaires), and age of menarche in the proband's mother and sisters as independent variables. Several models were developed in order to calculate the strength of association between the dependent variable (the presence or absence of menarche) and the independent variables. RESULTS: The average age of menarche was 12.4 years. The intake of the various types of foods was not consistent between the different age groups. In girls of 12 or younger, the age of menarche was found to be related to weight: Odds ratio (OR) = 7.06; (Confidence intervals (CI) = 2.80-17.6). On inclusion of various foods groups, the OR rose to 49.89 (CI = 40.85-60.84). In girls over 12, the age of menarche was essentially related to the intake of nuts and seeds (OR = 0.71, CI = 0.40-0.98). Inclusion of other foods groups decreased the OR (OR = 0.34, CI = 0.14-0.39). CONCLUSIONS: Significant statistical relationship between intake of nuts and seeds and the age of menarche was found.

Altered bioavailability due to changes in the formulation of a commercial preparation of levothyroxine in patients with differentiated thyroid carcinoma.

OBJECTIVES: In July 1995 we began noticing an unusually high rate of elevated TSH levels in patients with differentiated thyroid cancer treated with levothyroxine-specifically the brand Levothroid-becoming more obvious from September 1995. Faced with the possibility that these findings had some relationship to the drug taken, we carried out a prospective study, changing this brand of levothyroxine for another. DESIGN AND PATIENTS: We studied 58 patients with differentiated thyroid carcinoma (50 women and eight men; aged 22-75 years) who were being treated with levothyroxine and who had previously had adequate TSH suppression. Their Levothroid tablets were changed to the same dose of Dexnon tablets, and their clinical and analytical response was evaluated 2 months later. The patients were divided into two groups according to their TSH level at the start of the study: group 1, 42 patients with TSH > 0.2 mU/l (not suppressed) and group 2, 16 patients with TSH < or = 0.2 mU/l (suppressed). RESULTS: After 2 months with Dexnon the TSH levels in group 1 fell significantly (P < 0.0001) also decreasing in group (P < 0.09). The free T4 and free T3 rose significantly in both groups. After the change to Dexnon, 17 patients (40%) in group 1 had suppressed TSH and 26 (62%) had free T4 levels above the upper limit of normal vs none at baseline (P < 0.001). The group 2 patients maintained their inhibited TSH values after treatment with Dexnon, and the free T4 was above the upper limit of normal in 15 (94%) vs 3 (19%) at baseline (P < 0.001). The Levothroid tablets collected from the patients in both groups formed part of those which the manufacturer later withdraw from the market. These batches possessed the correct dosage, but they had been made from 'non-micronized' raw materials from another supplier. CONCLUSIONS: The most probable cause of the inadequate TSH suppression in our patients was the reduction in bioavailability in certain batches of Levothroid, although we are unable to rule out the possibility that the results obtained after the changeover to Dexnon were due to its greater bioavailability. Simple changes in the manufacture of levothyroxine tablets may produce important variations in their bioavailability, having an adverse effect on the clinical control of the patients, and causing extra expense by the need for repeated patient visits and thyroid function tests.

[Myocardial bridging. The role of microcirculation, coronary reserve and systolic endothelial injury]. / Puentes miocárdicos. Papel de la microcirculación, reserva coronaria y daño endotelial sistólico.

BACKGROUND: The relationship between myocardial bridging (MB) and ischemic heart disease is still controversial. However, a recent new evidence suggests that this relation is not by chance. PURPOSE: The purpose of our study was to review in a critical manner, the evidence for the relationship between MB and myocardial ischemia and its possible consequences. METHODS: We present 2 cases of our series and review the medical literature from January 1966 to January 1998 published and included in Medline and Current Contents. RESULTS AND CONCLUSIONS: The principal findings after this review were: 1) MB is not a normal variant; 2) The clinical impact of MB depends on its anatomical extension and degree of compressive effect; 3) The MB muscle is not similar to myocytes from other cardiac areas; 4) The environment surrounding coronary artery may be a crucial factor in determining whether the MB influences the induction of heart disorders or not; 5) The overshoot due to compressive effect on coronary artery might determine endothelial injury in the microcirculation post-MB; 6) In some cases, the systolic endothelial injury may contribute to release factors that are able to reduce the coronary reserve, resulting in myocardial ischemia; 7) The possible role of PTCA in this disorder still has to be proven. Surgical treatment should be considered when important myocardial ischemia had been demonstrated, even in those asymptomatic cases.

[Comparative analysis of reperfusion time in primary angioplasty vs thrombolysis. Success vs time]. / Análisis del tiempo de reperfusión entre angioplastía primaria y trombolisis: éxito vs tiempo.

UNLABELLED: We studied 398 patients with diagnosis of acute myocardial infarction who arrived within the first six hours of symptom onset that were treated with thrombolysis or primary angioplasty, they were divided in two groups: Group 1 (n = 198), those treated with 1.5 million U of streptokinase over 60 min and Group 2 (n = 200), those treated with primary angioplasty. In Group 1 the "pain-door" time was 3.7 +/- 1.7 hs vs 3.8 +/- 2.4 hs in group 2 (p = NS). The "door-needle" time was 48 +/- 12 min. compared with the "door-balloon" time of 84 +/- 30 min (p < 0.001). In Group 1, 154 (77.6%) of the patients had clinical of reperfusion after thrombolysis, 58 of them underwent coronary angiography and had an infarct related artery (IRA) patency rate of 45.3%. In Group 2 the IRA patency rate was 85.5% (p < 0.005). CONCLUSION: Thrombolysis was achieved in a lesser period of time but our findings showed that primary angioplasty was more effective obtaining a TIMI 3 flow.

Estudio longitudinal del impacto del tratamiento con infusores de insulina en variables psicológicas, la calidad de vida y el control glucémico de pacientes con diabetes mellitus tipo 1 / Longitudinal study of the impact of the treatment with insulin infusion in psychological, quality of life, and glycemic control of patient with type 1 diabetes mellitus

Introducción: Desde el estudio DCCT, han sido muchas las investigacionesque han intentado evaluar las distintas propuestas de terapia intensiva. Pocosestudios a largo plazo incluyen variables psicosociales. Objetivos: Evaluarvariables psicológicas y metabólicas en pacientes con diabetes tipo 1 tras 2años de tratamiento con infusión subcutánea continua de insulina (ISCI). Materialesy métodos: Veintidós pacientes con diabetes tipo 1 en tratamientocon múltiples dosis de insulina recibieron tratamiento con ISCI. Se realizó unaevaluación a los 6, 12 y 24 meses, utilizando diversos instrumentos como elBDI, el DQOL, la MHLC, el STAI y el cuestionario de miedo a las hipoglucemias.Se admitió un control glucémico adecuado con una HbA1c <7,5%. Elanálisis estadístico se realizó mediante pruebas no paramétricas y el coeficientede correlación de Pearson. Resultados: Los pacientes partían de una puntuaciónmedia en depresión de 9,55 ± 9,12 (media ± DT). En calidad devida, los datos iniciales fueron 92,95 ± 16,15, mientras que el nivel de HbA1cfue de 8,45 ± 1,59%. Al cabo de los 2 años de tratamiento, se aprecian mejorassignificativas en las puntuaciones obtenidas en depresión (p= 0,018),calidad de vida (p= 0,005) y control glucémico (p= 0,003). La ansiedad rasgoy el locus de control externo correlacionaron significativamente, encontrándoseuna fuerte relación entre el miedo a las hipoglucemias y las variablespsicológicas estudiadas. Los pacientes con mal control glucémico basal mejoraronal cabo de los 2 años de tratamiento. Conclusiones: Después de 2años con ISCI, los pacientes con diabetes tipo 1 mejoran significativamente sucalidad de vida, su control glucémico y su sintomatología depresiva(AU)

Introduction: Since the DCCT study, many studies have tried to assess differentintensive therapies. However, few long-term studies have included psychosocialvariables. Objectives: To evaluate psychological and metabolic variablesin patients with type 1 diabetes after 2 years of therapy with continuoussubcutaneous insulin infusion (CSII). Materials and methods: Twenty-twotype 1 diabetic patients treated with multiple daily injections were treated withCSII. An evaluation at 6, 12 and 24 months was performed, using several instrumentsas BDI, DQOL, MHLC and a questionnaire to evaluate fear of hypoglycaemia.Acceptable metabolic control was admitted with HbA1c <7.5%.Statistical analysis was realized using non parametric tests and Pearson’s correlationcoefficient. Results: Initially, patients had a mean score for depressionof 9.55 ± 9.12 (mean ± SD). In quality of life, initial values were 92.95 ±16.15, while the level of HbA1c was 8.45 ± 1.59%. After 2 years of treatmentwe found significant improvement in depression (p= 0.018) and quality of life(p= 0.005) scores and glycemic control (p= 0.003). Trait anxiety and externallocus of control showed a significant correlation, with a strong correlation betweenfear of hypoglycemia and the analyzed psychosocial variables. Patientswith bad basal glycemic control improved after 2 years of treatment. Conclusions:After two years with CSII, type 1 diabetic patients improve significantlytheir quality of life, glycemic control and depressive symptoms(AU)

La educación terapéutica de personas con diabetes. Experiencia del Servicio de Endocrinología y Nutrición del Hospital Universitario «Carlos Haya» de Málaga / Therapeutic education in people with diabetes. Experience from the Endocrinology and Nutrition Department of Carlos Haya University Hospital in Málaga, Spain

En la segunda mitad del siglo XX, la medicina ha cambiado más que en toda su historia anterior. Este cambio ha sido la consecuencia no sólo de los avances científicos y técnicos, sino también de los cambios del modelo social. Los pacientes han dejado de ser personas pasivas y han pasado a disfrutar de un creciente protagonismo en la toma de decisiones: es la manera de llevar a la práctica el principio de autonomía, que, junto con los principios de beneficencia y de justicia, constituyen los pilares básicos de la ética médica. Pero la autonomía no es real si el paciente no disfruta de los instrumentos para ejercerla realmente. La educación terapéutica es el mejor instrumento para transferir información desde el médico y el sistema sanitario hacia el paciente. La diabetes mellitus es el prototipo de enfermedad crónica susceptible de beneficiarse de la participación activa del paciente. Los programas de educación de pacientes diabéticos han pasado a formar parte de los espacios establecidos de atención clínica de la diabetes. Por lo general, hasta no hace mucho los servicios clínicos carecían de experiencia en la introducción de la educación como parte de la terapéutica clínica. No es sorprendente, pues, que la manera de organizar la educación de los pacientes haya sido muy diversa: dependía de la capacidad de cada servicio para dar respuesta a los nuevos retos, pero también, y sobre todo, de la sensibilidad y la cultura que se tuviera sobre la relación médico-enfermo. Así, aunque se ha hecho un esfuerzo por estandarizar la educación terapéutica, lo cierto es que ha habido tantos programas como espacios donde se ha puesto en marcha. En el presente artículo se reflexiona sobre la educación de pacientes desde la experiencia de más de 20 años en un servicio de endocrinología y nutrición

In the second half of the 20th century, the field of «Medicine» underwent more changes than throughout its entire previous history. This transformation has been the consequence not only of scientific and technical advances, but of changes in the social model as well. Patients have gone from being passive individuals to having an increasingly prominent role in the decision-making process. This is the manner of putting into practice the principle of autonomy, which, together with the principles of beneficence and justice, is a mainstay of medical ethics. However, this autonomy is not real if the patient is not provided with the tools he or she needs to actually exercise it. Therapeutic education is the best tool for transferring information from the physician and health care system to the patient. Diabetes mellitus represents the prototype of the chronic diseases that could benefit from the active participation of the patient. Education programs for diabetic patients have become a part of the conventional ambit of clinical care in diabetes. The staffs of clinical services generally lack experience in the introduction of education as a part of clinical therapeutics. Thus, it is not surprising that the approach to organizing patient education has varied widely. It has depended on the capacity of each service to respond to the new challenges, but, above all, on the existing sensitivity and culture with respect to the physician-patient relationship, as well. Although there has been an effort to standardize therapeutic education, the truth is that there have been as many programs as settings in which they have been introduced. In the present article, the authors reflect on patient education, following more than twenty years of experience in an endocrinology and nutrition department